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Stony Brook - Hand Replantation Surgery Survey II

Consent

STONY BROOK UNIVERSITY

RESEARCH CONSENT FORM

Project Title: Survey of Hand Surgeon Opinions and Beliefs Regarding Replantation
Principal Investigator: Alexander Dagum, MD
Study Coordinator: Jocellie Marquez, MD
Co-Investigators: Lawrence Hurst, MD, Julie Hong, BS, Miltiadis Tembelis BS, Michael Trostler, MD
Department: Plastic and Reconstructive Surgery

You are being asked to be a volunteer in a research study.

PURPOSE
The purpose of this study is:
Determine the current practices and opinions regarding hand and upper extremity replantation among practicing hand surgeons.  The wide range of judgement is often based on experience, we aim to determine what the trend in current practices are and how they compare to a survey that was sent out 5 years ago.
 PROCEDURES
If you decide to be in this study, your part will involve:
  • You are only required to complete this survey instrument once, please refrain from repeat submissions.  Please answer as honestly as you can.
  • If you do not feel comfortable answering part of the survey you may leave it blank.
  • After you complete the survey you will not be able to withdraw your answers as they are anonymous we will not be able to filter out yours.
RISKS / DISCOMFORTS
The following risks/discomforts may occur as a result of you being in this study:
  • There are no expected risks/discomforts as a result of this study.  This is a short survey that should not take more than 10-15 minutes of your time.
BENEFITS
  • There are no direct benefits to you expected as a result of your participation in this study.  You will be assisting in adding to the collective knowledge of the field and where the current practices stand on a national level.
PAYMENT TO YOU 
  •  You will not be paid for taking part in this study.
CONFIDENTIALITY 
Protecting Your Privacy in this Study
All the information we get about you will be not be linked to you at all. We will do this by not collecting any information that could link you in any way to the answers you give us for our study. All the study data that we get from you will be kept locked up. Your name or any identifiable data will not be collected at any time during this study.
. When you sign the consent form at the end, it means:
  • That you have read this section.
  • That you will allow the use and reporting of your health data as described above.
  • That you have received a form from the University Hospital. It is called the Notice of Privacy Practices form.
COSTS TO YOU  
  • There are no costs to you for being a part of this study.
ALTERNATIVES
  • Your alternative to being in this study is to simply not participate.
IN CASE OF INJURY/CONCERN
If you are injured or have concerns as a result of being in this study, please contact Dr. Alexander Dagum at telephone # 631-444-8210. The services of Stony Brook University Hospital will be open to you in case of such injury. However, you and/or your insurance company will be responsible for payment of any resulting treatment and/or hospital stay.
YOUR RIGHTS AS A RESEARCH SUBJECT  
  • Your participation in this study is voluntary. You do not have to be in this study if you don't want to be.
  • You have the right to change your mind and leave the survey at any time without giving any reason, and without penalty.
  • You will not be able to retract your answers after submission as they are anonymous and cannot be filtered from other survey answers.
QUESTIONS ABOUT THE STUDY OR YOUR RIGHTS AS A RESEARCH SUBJECT  
  • If you have any questions, concerns, or complaints about the study, you may contact Dr. Alexander Dagum at telephone # 631-444-8210.
  • If you have any questions about your rights as a research subject or if you would like to obtain information or offer input, you may contact the Stony Brook University Research Subject Advocate, Ms. Lu-Ann Kozlowski, BSN, RN, (631) 632-9036, OR by e-mail, lu-ann.kozlowski@stonybrook.edu
  • Visit Stony Brook University’s Community Outreach page, http://research.stonybrook.edu/orc/community.shtml#overview-of-volunteering-in- research
  • for more information about participating in research, frequently asked questions, and an opportunity to provide feedback, comments, or ask questions related to your experience as a research subject
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